Highlights From ACG 2013
By Dee Rapposelli
The American College of Gastroenterology Debuts ACG Hepatitis Circle
To provide tools to manage patients with hepatitis C virus (HCV) infection and other variants of hepatitis, the American College of Gastroenterology (ACG) was aggressively encouraging participation in its ACG Hepatitis Circle at its annual scientific meeting and postgraduate course, ACG 2013, which took place October 11 to 16 in San Diego, California. The ACG Hepatitis Circle is an online community where physicians can collaborate and share knowledge about hepatitis, with particular emphasis on the many facets of HCV infection screening, diagnosis, and care.
This dynamic online forum is comoderated by David E. Bernstein, MD, chief of the Division of Gastroenterology, Hepatology and Nutrition at the North Shore–Long Island Jewish Medical Center in Manhasset, New York, and Paul Kwo, MD, professor of medicine in the Division of Gastroenterology and Hepatology at the Indiana University School of Medicine in Indianapolis. Physicians who are ACG GI Circle members can access the ACG Hepatitis Circle by using their login at https://acghepatitis- circle.within3.com. Otherwise, nonregistered members who want to join the ACG Hepatitis Circle should e-mail a request to the ACG at email@example.com.
Blood Test May Be Diagnostic for Irritable Bowel Syndrome
A blood test that measures antivinculin antibodies may be a simple and efficient method of diagnosing irritable bowel syndrome (IBS), according to a study presented at ACG 2013 by Mark Pimentel, MD, director of the Gastrointestinal Motility Program at Cedars-Sinai Medical Center in Los Angeles, California. Dr Pimentel, together with researchers from Beth-Israel Deaconess Medical GAS in Boston, Massachusetts, analyzed the serum (via enzyme linked immunosorbent assay [ELISA]) of 165 patients with Rome-positive IBS, 30 patients with documented inflammatory bowel disease (IBD), and 26 healthy controls to identify antibodies to human recombinant vinculin. Presence of these antibodies suggests an immunologic response to gastroenteritis, a predisposing risk factor of IBS.
The research team found that the optical density of antivinculin antibodies on ELISA was significantly greater in patients with IBS than patients with IBD or controls and that antivinculin antibodies were the highest in patients with a history of acute gastroenteritis. This is the first serum-based diagnostic test studied for IBS and represents a breakthrough in distinguishing IBS from IBD and avoiding unnecessary diagnostic tests, according to Dr Pimentel.
Lower Esophageal Sphincter Electrical Stimulation Effective for Refractory GERD
Interim results of an international, multicenter trial, presented at ACG 2013 by Peter Siersema, MD, PhD, chief of the Department of Gastroenterology and Hepatology at the University Medical Center in Utrecht, The Netherlands, suggest that lower esophageal sphincter electrical stimulation therapy (LES-EST) is effective for refractory gastroesophageal reflux disease (GERD). To date, 25 patients with GERD have been enrolled and received LES-EST implants, although 1 patient was discontinued due to a small bowel trocar perforation that occurred during the implant procedure. Eligible patients are those partially responsive to proton pump inhibitor (PPI) therapy with an off-PPI GERD health-related quality of life (HRQL) score of greater than 20 and a greater than 5-point improvement in HRQL score while on a PPI. Other eligibility requirements are an LES end-expiratory pressure greater than 5 mmHg, an esophageal pH less than 4 for more than 5% of a 24-hour period, a hiatal hernia smaller than 3 cm, and esophagitis.
Of the remaining 24 patients currently in the study, 20 have completed their 3-month evaluation, and of these, 17 have completed their 6-month evaluation. A significant improvement in GERD-HRQL scores compared with baseline was seen at both 3 and 6 months. Fifteen (88%) of the patients evaluated at 6 months reported being able to discontinue PPI medication. Most adverse events that occurred were nonserious, and no stimulation-related gastrointestinal adverse events or sensations were reported.
Knowledge Deficit Demonstrated for Proton Pump Inhibitor Use in the Intensive Care Unit
More than half of patients in intensive care units (ICUs) may be inappropriately receiving PPIs, reported Sonaly Patel, MD, during a poster session at ACG 2013. Dr Patel, who is an assistant professor at Drexel University College of Medicine in Philadelphia, and her colleagues there sought to gauge appropriate use of PPIs in the intensive care setting. The research team conducted a retrospective chart review to determine the rate of inappropriate initiation of PPI therapy in the ICU, the subsequent rate of continuation of the PPI after hospital discharge, and the rate of bleeding in patients not given a PPI. A questionnaire regarding knowledge of stress ulcer prophylaxis and guidelines of the American Society of Health-System Pharmacists (ASHP) also was given to the prescribing physicians. The charts of 477 patients admitted to the ICU, dating from January to December 2012, were reviewed. A total of 212 patients who were already receiving acid suppression therapy were excluded from the analysis. Of 177 patients given stress ulcer prophylaxis following admittance to the ICU, 101 (57%) were inappropriately given a PPI, but of these, only 3 were discharged with a PPI prescription.
Findings from the questionnaire on ASHP guidelines regarding stress ulcer prophylaxis suggested that prescribing physicians were not well informed. The 50 residents who staffed the ICU under study responded correctly to only 42% of the questions, translating to a knowledge deficit of 58%. Inclusion of a PPI in the ICU admission order set likely led to reflexive ordering of the agent, said Dr Patel. She added that most patients were not discharged with a PPI prescription because protocol is to confirm diagnosis and need for medication before discharge. In light of the findings and given the effect of PPI use on Clostridium difficile infection and pneumonia and the associated costs, Dr Patel and colleagues have proposed that residents receive laminated cards with ASHP guidelines, the guidelines be posted on all computers in the ICU, and PPIs be removed from the admission order set.
Eosinophilic Esophagitis Linked to Ulcerative Colitis
Concomitant eosinophilic esophagitis (EoE) and IBD is thought to be rare, but a multicenter research team from the Miraca Life Sciences Institute demonstrated a strong link between the 2 diseases in a poster presentation at ACG 2013. The team used the Miraca Life Sciences database to examine a large cohort of patients with esophageal eosinophilia to determine whether increased levels of eosinophils were associated with the presence of IBD. During a poster session, Maria McIntire, MD, a researcher at the Newton, Massachusetts branch of Miraca Life Sciences Research Institute, explained that histopathologic, demographic, and clinical information from all patients who had simultaneous esophageal and ileocolonic biopsies between January 2008 and June 2012 were extracted from the database. The study population, which excluded patients with a history of gastrointestinal cancer, was stratified according to whether the patients had less than 15, 15 to 60, or more than 60 eosinophils per high-power field (eos/HPF) in their esophageal squamous mucosa.
The prevalence of ulcerative colitis (UC) and Crohn’s disease (CD) was then determined for each group. Of the 48,947 patients in the Miraca database who had both esophageal and ileocolonic biopsies, 96% had less than 15 eos/HPF and 4% had more than 15 eos/HPF in their esophageal squamous epithelium. It was observed, however, that, as the numbers of eos/HPF increased, UC became progressively more frequent, with an odds ratio of 1.93 (95% CI, 1.38-2.69; P<.0001). An increased prevalence of CD, however, was only seen in patients with greater than 60 eos/HPF, and the overall difference, compared with patients with less than 15 eos/HPF, was not significant. Based on these findings, the researchers concluded that patients with increased esophageal eosinophils—particularly those with greater than 60 eos/HPF (suggesting presence of EoE)—are almost twice as likely to also have IBD, primarily in the form of UC.